Download - Gynaecological Bleeding
Gynaecological bleeding
1. Abnormal uterine bleeding
2. Postmenopausal bleeding
3. Prepubertal vaginal bleeding
4. Contraceptive side effects
Stefan Gebhardt [email protected]
Normal menstrual cycle
0 14 28
Estradiol
Progesterone
LH
Anovulation
0 14 28
Estradiol
Progesterone
LH
FSH
Gynaecological bleeding
• Estrogen withdrawal
• Estrogen breakthrough
• Progesterone withdrawal
• Progesterone breakthrough
Estrogen withdrawal
• After oophorectomy
• After withdrawal of exogenous
estrogens
• Midcycle
Estrogen withdrawal
Estrogen breakthrough
• Constant low doses- prolonged, intermittent
spotting
• Sustained high levels of estrogen- prolonged
periods of amenorrhoea followed by profuse
bleeding
Estrogen breakthrough
Progesterone withdrawal
• Removal of corpus luteum (normal
menstruation)
• Discontinuation of progesterone treatment (eg
Riley test)
– Only if endometrium proliferated by estrogen
Progesterone breakthrough
• Only in the presence of unfavourably
high ratio of progesterone to estrogen
– eg long-acting progesterone only
contraception (Depo Provera, Nur Isterate
etc.) or oral contraception
1. Abnormal uterine bleeding
• Dysfunctional uterine bleeding
– No specific cause found
– Failure to control with hormonal therapy
excludes diagnosis
• =often anovulatory
Diagnosis
• Medical and gynaecological history
• Pregnancy test
• Gynaecological examination
Management on clinical findings
• Women 20-35
• Normal weight
• No clear risk factors for STI
• No signs of excess androgens
• Not using any hormones
• No abnormal findings
Treatment
Progesterone therapy
• Medroxyprogesterone acetate (Provera)
or Norethisterone (Primolut-N) 10 mg
per day for 10-20 days per month
• Oral contraception if desired
Treatment
Oral contraception
Low dose combination monophasic
• Brevinor Nordette Femodene
• Minulette Melodene Minesse
• Mirelle Marvelon Mercilon
Treatment
Progesterone therapy
• If progesterone does not correct
bleeding, do further diagnostic
procedures
Diagnostic procedures
• Pelvic ultrasound
• Endometrial sampling
• D&C
• Clotting profile
• Hysteroscopy
Treatment
Estrogen therapy
• Prolonged bleeding, progesterone therapy,
thin endometrium (ultrasound)
• Conjugated estrogen (Premarin 1.25mg) daily
for 7-10 days, followed by Estrogen +
progesterone (Provera 10 mg daily) for 7 days
Treatment
Estrogen therapy
• High doses of estrogen temporarily
stops most dysfunctional bleeding
• Conjugated estrogen (Premarin
1.25mg) daily for 7-10 days
Treatment- emergency
Estrogen therapy
• Conjugated estrogen (Premarin 1.25mg) 6
hourly for 24 hours, followed by 1.25 mg daily
for 7-10 days, followed by combination E+P
• Or 25 mg Premarin IV every four hours until
bleeding stops (+ resuscitation)
Treatment- other modalities
• Antifibrinolytic drugs
– Tranexamic acid (Cyklokapron)
1g 3-4x/day for 1st four days of cycle
• Nonsteroidal anti-inflammatory drugs
– 1st four days of cycle
Treatment- other modalities
• Medicated intra-uterine system (Mirena)
reduce blood loss in menorrhagia
• Danazol (side-effects- do not use)
• GnRH analogues (eg Zoladex) < 6
months (expensive, side effects)
Treatment- special cases
• Patient >35-40 years- always do
diagnostic procedures before starting
therapy
• Polyps, miomas, hyperplasia,
endometrial or cervical cancer etc
Treatment- special cases
• Adolescents- usually anovulatory
• Can be conservative (reassurance,
counseling, menstrual calendar)
• Hormone therapy
Treatment- surgical
• Endometrial ablation
• Hysterectomy
2. Postmenopausal bleeding
• Menopause: diagnosis retrospective• Postmenopausal bleeding: any vaginal
bleeding (even bloody discharge) after at least 6 months amenorrhoea, at the age of the menopause
• Malignant until proven otherwise• Menstruation after 55/ abnormal
menstruation ominous
• Atrophic vaginitis (most common)
• Hyperplasia
• Polyps
• Exogenous estrogens (HRT)
• Malignancy (endometrial, cervical, vagina etc)
• Other: trauma, bladder, rectum
CAUSES
• History
• Clinical examination
• Cytology smear
• Ultrasound
• Histology
Management
Postmenopausal bleeding
VCE smear
Cytology
V C E
Ultrasound
Ultrasound: atrophy
•Thickness: 4mm or less (5mm)
•Regular
•No fluid collections
Ultrasound: histology
•Thickness: >4mm
•Irregular
•Fluid collections (cone biopsy!)
Histology
•Office procedure (Accurette, Pipelle, etc)
•Formal dilation and curettage (differential, DD&C)
Management
•Atrophy
•local estrogen cream for one month
•hormone replacement therapy
Management
•Malignancy
•refer to gynaecologist/ oncologist
• Simple hyperplasia Risk for Carcinoma
– without atypia 1%– with atypia 8%
• Complex hyperplasia– without atypia 3%– with atypia 29%
Endometrial hyperplasia
Management
•Hyperplasia: without atypia
•continuous progesterone treatment (e.g. medroxyprogesterone acetate 5 mg daily for three months) followed by repeat histology
•if normal then, consider hormone replacement therapy
Management
•Hyperplasia: with atypia
•Total abdominal hysterectomy and bilateral salpingo-oophorectomy advised
•Polyps: remove with D&C (histology)
3. Prepubertal vaginal bleeding
• Precocious puberty (breasts <8 years; menarche
<9 years)
• Foreign bodies (offensive discharge)
• Vaginitis (atrophic)
• Tumours (cervix, vagina, uterus)
• Accidental ingestion of hormones (Mother)
Prepubertal vaginal bleeding
• Assessment of secondary sexual
characteristics
• Proper examination (anaesthesia if
necessary)
• Treat cause
Prepubertal vaginal bleeding
• Precocious puberty (breasts <8 years; menarche <9 years)
– Refer to endocrinologist
• Foreign bodies (offensive discharge)
– Remove
• Vaginitis (atrophic)
• -Estrogen cream + antibiotics
• Tumours (cervix, vagina, uterus)
– Refer to oncologist
• Accidental ingestion of hormones (Mother)
• -Conservative
4. Abnormal bleeding on contraceptives
• Satellite symposium: Update in Family Planning
• 23 August 2002
• Bellville Park Campus + 23 other venues in South
Africa
• Enquiries Judy Geldenhuys tel 938 4504
4. Bleeding on contraceptives
• Slight bleeding– exclude pathology (ectopy, polyps)
– reassure
– bleeding only needs treatment if it persists or is excessive
4. Bleeding on contraceptives
• Bleeding shortly after commencement of depo MPA– repeat another 150-300 mg
– only instance where this approach will work
– based on inadequate endometrial suppression
4. Bleeding on contraceptives
• Bleeding after long-term use of depo MPA– Usually due to atrophic endometrium
– Exclude pathology
– Add estrogen 20 microgram po, daily for three weeks/month x2-3 months (+ continue Depo)
4. Bleeding on contraceptives
• Breakthrough bleeding on oral contraceptives– Exclude pathology– In first half of cycle- usually due to insufficient
estrogen stimulation– Minor bleeding- continue pill and wait– Change to pill with higher estrogen content if
bleeding persists (eg Biphasil)– Regard severe breakthrough bleeding as a
menstruation and start a new packet
4. Bleeding on contraceptives
• Breakthrough bleeding on oral contraceptives– In second half of cycle- usually due to
insufficient progestogen stimulation
– Change to pill with higher progestogen content (eg Nordiol, Ovral, Norinyl)